Laparoscopic lavage and drainage for Hinchey III diverticulitis. Review of technical aspects

The surgical treatment for patients with generalized peritonitis complicating sigmoid diverticulitis is currently debated; particularly in case of difuse purulent contamination (Hinchey 3). Laparoscopic lavage and drainage (LLD) has been proposed by some authors as a safe and efective alternative to single- or multi-stage resective surgery. However, among all the diferent studies on LLD, there is no uniformity in terms of surgical technique adopted and data show signifcant diferences in postoperative outcomes. Aim of this review was to analyze the diferences and similarities among the authors in terms of application, surgical technique and outcomes of LLD in Hinchey 3 patients. A bibliographical research was performed by referring to PubMed and Cochrane. “Purulent peritonitis”, “Hinchey 3 diverticulitis”, “acute diverticulitis”, “colonic perforation” and “complicated diverticulitis” were used as key words. Twenty-eight papers were selected, excluding meta-analysis, reviews and case reports with a very small number of patients. The aim of this review was to establish how LLD should be done, suggesting important technical tricks. We found agreement in terms of indications, preoperative management, ports’ positioning, antibiotics, enteral feeding and drain management. On the contrast, diferent statements regarding indications, adhesiolysis and management of colonic hole and failure of laparoscopic lavage are reported. A widespread difusion of LLD and standardization of its technique are impossible because of data heterogeneity and selection bias in the limited RCTs. It is necessary to wait for long terms results from randomized clinical trials (RCTs) in progress to establish the efcacy and safety of this technique. More importantly, an increased number of highly skilled and dedicated colorectal laparoscopic surgeons are required to standardized the procedure.